Abstract

When accessing healthcare services, LGBT+ individuals are often exposed to segregating and marginalizing discourses. Knowledge about how such experiences are reflected in the moral world of LGBT+ individuals living in Turkey is limited. This study examined LGBT+ individuals’ lived experiences when utilizing healthcare services. The findings are discussed in terms of moral discourses related to LGBT+ individuals’ gender identity and sexual orientation. A qualitative field study was conducted using semi-structured interviews with fifty-five LGBT+ individuals from Turkish cities who were in contact with various non-governmental organizations that conduct studies on gender identity and sexual orientation. A questionnaire was administered with items on participants’ demographic information, experiences, behavioural patterns, and knowledge regarding healthcare services. The data were analysed thematically. The findings were evaluated within the framework of “access to healthcare service” theme related to “healthcare service demand” context. Additionally, the “interaction with physicians” theme was addressed in the context of “physician–patient/counselee relationship.” LGBT+ individuals state that they are exposed to stigmatizing and segregating discourses by healthcare professionals, which might pose an obstacle for adaptive health-seeking behaviours. These results suggest that physicians’ professional approach has a considerable influence on LGBT+ individuals’ capacity for utilizing healthcare services.

It is unknown whether the experiences of LGBT+ individuals in Turkey within healthcare settings have similarities with those experienced by individuals in Western countries. Due to the limited number of studies assessing gender identity and sexual orientation in Turkey, it is difficult to fully understand how healthcare disparities impact the general LGBT+ population in the country. Numerous media reports and legal proceedings cited by the Turkish Medical Association (TMA) and various non-governmental organizations suggest that the discrimination faced by LGBT+ individuals negatively affects their access to healthcare services (Radikal Newspaper 2014; Lambda İstanbul 2010; Kaos GL, 2015; TMA 2016). However, in-depth knowledge regarding, for example, how LGBT+ individuals prefer to address the negative attitudes and procedures in the healthcare settings to which they are exposed is not readily available.

Results of a recent study conducted with 2,875 respondents help depict this situation in Turkey. Those findings revealed that several participants either did not receive any treatment or delayed their treatment due to a fear of experiencing discrimination. Additionally, LGBT+ individuals were negatively affected by a lack of insurance and not being able to receive appropriate mental healthcare due to prohibitive costs. Furthermore, LGBT+ respondents were not well informed about how to access sexual healthcare services. One key barrier was that healthcare professionals’ general attitudes toward homosexual and/or trans identities were to view these as illnesses (Göçmen and Yılmaz 2017).

The goal of the present study was to obtain insights on what LGBT+ individuals experience when needing healthcare services in Turkey—a culturally cosmopolitan, yet politically and societally tensioned, country. A thematic analysis was performed based on the restricted access to healthcare services for LGBT+ individuals and the biases experienced within healthcare settings. We believe that such knowledge will provide a basis for scientific and political interventions for increasing LGBT+ individuals’ quality of life and attaining equality.

Methods

Aims and Setting

The aim of this study was to assess how activist LGBT+ individuals, reflecting on their own bodies, sexuality, and gender evaluate their experiences when receiving healthcare services.

Participant Recruitment

Participants consisted of fifty-five LGBT+ individuals (lesbians, gay men, bisexual women, bisexual men, trans women, and trans men) aged eighteen to sixty-five years old, who were in contact with various non-governmental organizations working with gender identity and sexual orientation issues. LGBT+ individuals with different social statuses, living in various Turkish provinces, participated.

Snowball sampling was used to achieve the target sample via non-governmental organizations active in the field of gender identity and sexual orientation, as well as through LGBT+ student communities in universities throughout Turkey.

Information regarding sex, marital status, level of education, and religious affiliation are shown in Table 1. Except for one married participant, all participants were single. One participant noted, “I'm married in my own way,” which we classified as “other.” Participants were mostly non-religious individuals. Two participants did not report their religious affiliations and were classified as “other.”

Data Collection

Face-to-face, in-depth interviews were conducted with the participants. Questions were classified as “demographics,” “experience,” “behaviour,” “knowledge,” and “emotions.” The key research questions are as follows: i) Have you had any medical condition that necessitates treatment in the last six months? If so, did you apply for treatment? ii) What determines your behaviour when you need healthcare? iii) Do you think that LGBT+ individuals have been neglected in terms of their access to healthcare services? iv) What do you feel when you have a medical problem where you need to tell your doctor your sexual history? Open-ended questions were prepared via discussion with specialists in the research group.

For participants who were believed to have important information, and with whom it was impossible to meet in person, interviews were conducted via video chat software online. Voices from five participants could not be recorded due to either technical disruption during the interview or voice recording refusal. Written information from these participants was still acquired.

Data Analysis

The interviews were transcribed into raw logs. All participants were assigned a protocol number, and raw logs were archived.1 A rough reading of raw logs was conducted to gain a general understanding of the interviews (Step 1). Expressions regarded as relevant answers to the questions were sorted and clustered (Step 2). Next, these responses were reviewed and matched with themes (Step 3). The research team discussed and structured the themes (Step 4). Context, themes, and sub-themes were determined and tables were created (Step 5). The relationships between these elements were defined, and semantic homogeneity was constructed (Step 6). Findings were interpreted in comparison with data obtained from prior relevant studies and discussed to gain a comprehensive perspective (Step 7).

Ethics Statement

The Ankara University Ethics Committee on Non-Clinical Researches on Human Beings approved this study. Informed consent was obtained from each participant. In-depth interviews were conducted between June 28, 2013, and September 1, 2014.

Research Limitations

Volunteers who attended political activities as part of the growing LGBT+ movement in Turkey were included in our study. One of the limitations of this procedure is that we could not acquire information from the experiences of non-activist LGBT+ individuals when accessing healthcare services.

In-depth interviews were audio recorded after obtaining participants’ consent. A few of the interviewees did not want their voices to be recorded; therefore, script notes were taken. In all cases, the interviewer took post-interview notes. Additionally, audio from some of the interviews could not be transcribed due to technical disruptions. Data loss arising from these aforementioned issues could be considered a limitation of the present study. Finally, several participants were uncomfortable with the tape recorder, which might have interfered with their ability to be fully forthcoming in their disclosures.

Findings

The majority of interviewees reported needing healthcare services during the last six months and to have visited a healthcare centre. Thus, the main theme “access to healthcare service” and relevant themes were determined in the context of “healthcare service demand.” Furthermore, the main theme “interaction with physicians” and relevant sub-themes were specified in the context of “physician–patient/counselee relationship” (Table 4).

Having Problems with Access to Healthcare Services

Most participants declared that they had problems accessing healthcare services due to being exposed to discrimination, not having social insurance, being exposed to prejudice, maltreatment, and marginalization, difficulty in self-expression, and ignorant and inexperienced physicians. The majority of transgender participants disclosed problems they experienced during the sexual transformation process.

Discrimination

Many participants stated that they frequently faced discrimination within a healthcare setting. Behaviours classified under this theme were reflected in the perceived exclusion from receiving healthcare services because of participants’ sexuality. However, the data do not contain sufficient information regarding the reasons for this frequently experienced discrimination.

(...) two of my trans friends (...) suffered substantial damages; they had housebreakings … their houses were looted, and the girls were clobbered. Their hospitalization process was problematic. The ambulance at the door rejected taking them to the hospital and insisted that we should transfer them by a taxi. When we went to the hospital, we could not find a stretcher for them. They had to wait at the doorstep of the hospital for a very long time, lying on the ground. After waiting on stretchers … for hours, they were told that they could not be hospitalized. (MtF.14.09)

Not Having Social Insurance

Most of the transgender participants explained that they could not afford their own health expenses due to not having social insurance, which was a more frequent issue compared to gay, lesbian, and bisexual participants.

LGB individuals are luckier than transgender individuals regarding accessing healthcare services. (…) Unfortunately, transgender people are out of contention. Unlike LGB individuals, they are noticed due to their existence and cannot be invisible. Their legal rights, constitution-based health, accommodation rights, and rights to social insurance are violated because of their visibility. (MtF.14.09)

Prejudice

The majority of participants gave examples of experiences suggesting that when they applied to a healthcare organization, other people either displayed stereotyped approaches towards them (because of participants’ appearance, manners, speech, and/or other unidentified reasons) or displayed negative discriminatory behaviours.

A doctor said that he wouldn’t examine me because he didn’t favour such a condition. I had to go to the emergency unit. Even though another doctor directed me to the emergency room, the doctor in charge did not treat me because he thought that my condition was not emergent. They refuse you in different ways with various excuses. (FtM.14.04)

Maltreatment

Participants mentioned that their personal rights were disregarded during treatment. Several participants described their experiences, suggesting that they were deprived of adequate treatment. Some stated that they were exposed to adverse behaviours from healthcare professionals and other employees when receiving treatment (Table 4). For example, as participants put it, physicians purposefully delayed treatment, the treatment was interrupted for no reason, and/or medical procedures were performed without informed consent. Moreover, other experiences leading to humiliation, mocking, abasement, insults, and/or not being respected adequately were reported. Lastly, participants reported being exposed to hateful looks, verbal violence, and even sexual harassment within healthcare settings.

(…) I punched the window. Blood was gushing forth in between my fingers as I went to the doctor. (…) When he saw me, he was yelling at me, saying “Let this fucking poof die.” (MtF.14.13)

Marginalization

Marginalization and exclusion were emphasized in experiences where participants felt they were regarded as different and threatening, trivialized, despised, and made insignificant. Related experiences were as follows: physicians interrupted service provisions, or never provided services, as the physician disliked the participant’s appearance, attitude etc., or physicians were indifferent toward the participant.

The doctor says “that’s what you are, you should be as such” and touches you, but the thing he touches is not something that belongs to your body. While he listens to your heartbeats, for example … he touches something [the breasts] that he doesn’t want to exist on your body. He expects you to put on makeup and grow your hair, but he thinks based on normal concepts in the society. (FtM.14.10)

Self-censorship

Most participants reported difficulty expressing themselves in a healthcare setting and stated that they cannot establish a trust-based relationship with healthcare professionals or institutional officials. Participants gave clues about the reasons for this distrust by saying they were afraid of being misunderstood, of being subjected to adverse treatment effects, and of being stigmatized. They also added that they refrained from seeking out healthcare professionals, feeling discomfort when in the presence of these professionals and feeling that professionals are ashamed of them. Besides, some mentioned that they hesitated to see a physician due to the perceived negative consequences of their test results to be notified to their families or to certain official bodies.

(…) I had once told that I was a homosexual, and I had some risky relationships when I was referred for an HIV test. However, since I abstain from the risk of these examinations being reported and notified to [home] addresses and also because of the psychosexual irregularity report required for the national military service, I could not behave comfortably. (G.14.06)

Self-Perception

A few participants mentioned that they had regarded being LGBT+ as a disease when first exposed to information regarding gender identity and sexual orientation.

I regarded myself as a patient. I sought treatment methods. On the Internet, it was written somewhere that “there is a treatment,” whereas some sites mentioned that “there was none, and it was congenital.” I always wanted to get treatment. But as I began to understand [that it is not a disease], I quit. (G.14.16)

Most participants expressed that they had problems when disclosing their gender identity and sexual orientation to their families. Participants who were not supported by their families stated that their families directed them to medical treatment.

I was detached from life for a long time and gained too much weight because of the so-called “treatment” administered by a physician to whom my family took me. My family wanted the doctor to correct me, namely their homosexual child, and he harmed my health, believing that he was administering the proper treatment. (MtF.14.05)

Physician Ignorance and Inexperience

A majority of participants described experiencing some problems when needing healthcare services due to physicians’ ignorance and inexperience regarding gender identity and sexual orientation. Indirect consequences were that participants frequently felt obliged to explain themselves, exposing them to an inefficient course of healthcare services resulting in lost time and rising costs.

Apart from those who think that homosexuality is a disease, even a large number of people who don’t regard homosexuality as a disease don’t know what to do. (…) Unfortunately, although the physicians went beyond the idea of disease, they are not aware of how to behave or how to handle it. (L.14.04)

Sexual Transformation Process

Transgender participants reported various negative experiences over the course of their sexual transformation process. One stated as follows:

(…) [The hospital] is a public domain; it’s not easy to enter. There is a reaction; recently, a friend had an operation. She went to a gynaecologist after the transition process, but her doctor didn’t treat her, because he didn’t approve of the condition. I mean … there is a great disadvantage in a country with such physicians. Even seeing a dentist is very difficult, let alone consulting a gynaecologist. (G.14.07 )

Having no Problems Accessing Healthcare Services

Some participants expressed that they had no problems accessing healthcare services, as they were able to address their healthcare needs abroad, through private healthcare institutions, and/or they had a family member working in a medical institution. This theme is exemplified as follows:

I have a great prejudice toward public hospitals. While I am being taken care of like a princess in private hospitals, I’m ignored at public hospitals. Already, in public hospitals, nobody is being taken care of, and LGBT individuals are mistreated even worse. (MtF.14.04 )

Relationship Between Physicians and the Patient/Counselee

Communication with physicians, having positive communications, and not having positive communications emerged as the key theme and sub-themes affecting participants’ access to healthcare.

Being Able to Establish Positive Communication

Participants mentioned feeling comfortable and trusting of certain healthcare professionals as long as professionals communicated positively with the participants. Otherwise, when not perceiving any sign of marginalization or negative discrimination in physicians’ behaviours, participants did not report difficulty expressing themselves.

I had refrained a lot when I first went there. But the manners of the physicians, the approach of healthcare professionals, and how they informed me, etc., were friendly and objective; I felt more comfortable during my next visits. (G.14.11)

Not Being Able to Establish Positive Communication

Several participants said that they took into account the language physicians used when disclosing sexual histories.

Being perceived as a heterosexual annoys me—being perceived like that from the moment of entering the hospital and being asked questions related to it. The physician who asked “how often do you have sex?” is more valuable to me than a physician asking “are you married?” The first one is less heterosexist. I can say to a physician who approaches me like that “I have a girlfriend,” but I disregard the second physician by saying “No, I’m not.” (…) it is tiring explaining to people that I am a homosexual every other day. (BW.14.02)

Several participants mentioned their weariness when physicians did not understand the mood of patients/counselees and requested repetitive clarifications regarding their gender identity and sexual orientation. LGBT+ individuals who cannot communicate positively with their physicians expressed that they felt nervous, worried, and/or discomforted.

Discussion

The present findings suggest that activist LGBT+ individuals in Turkey have varied experiences regarding their access to healthcare services. The majority of the participants reported not trusting the healthcare system in Turkey and, therefore, self-selected against medical help. Some participants noted that their healthcare needs were being met by foreign providers abroad or through family members in the medical profession. Conversely, some participants do access healthcare services without having any ethical issues by establishing positive communication channels with providers.

Healthcare related experiences for most of the participants do not diverge significantly from problems reported by LGBT+ individuals across Western countries. Additionally, recent studies have obtained similar findings regarding access to healthcare services, including a lack of social insurance, exposure to prejudice/maltreatment/marginalization, having difficulty with self-expression, encountering ignorant and inexperienced physicians, and difficulties with sexual transformation procedures (Maragh-Bass et al. 2017a, 2017b; Murphy 2015; McLaughlin et al. 2012; Friedman et al. 2011). Very few studies in Turkey point out that LGBT+ individuals confront maltreatment across numerous spheres of life, particularly healthcare systems, due to their gender identity and sexual orientation (Göregenli 2011; Lambda İstanbul 2010; Aydın 2007; Lambda İstanbul 2006).

The participants reported that being exposed to discrimination is a significant problem. Some noted that they had the impression that several physicians disapprove of LGBT+ individuals’ sexual existence for religious or moral reasons and refuse to provide treatment. The perception that physicians deprive patients of treatment because of deviant religious and/or moral norms poses a risk for LGBT+ individuals. The underlying premise may be that the acceptability of an act or behaviour is debatable from a religious point of view (Murphy 2015), which might result in excluding people with different worldviews. Assuming that the family unit is the intersection point between religious and moral values within Turkey, sexual practices (except for heterosexuality) are either ignored or rejected. This situation might cause LGBT+ individuals to suffer greatly within an oppressive environment. For example, one recent Turkish news programme reported that a gynaecologist stated that he would not administer treatment because he did not approve of the gender identity of a trans female patient (Radikal Newspaper 2014). This event was criticized by non-governmental organizations and professional bodies, including TMA, which imposed a warning penalty on the physician: “Rejection should be based on a reasonable and understandable reason and should not rely on a reason accepted as a crime” (Bianet News 2016).

Being deprived of social insurance was perceived to be one of the major problems related to health policies preventing participants from receiving healthcare services. The vast majority of transsexuals in our study who did not have health insurance reported problems with affording health expenditures. Another recent study demonstrated that LGBT+ individuals frequently consult emergency departments where health services are free of charge, even if they believe that primary care services would be more effective. For this reason, emergency departments may be and important contact point with LGBT+ individuals (Maragg-Bass et al. 2017b). Establishing a trustful physician–patient/counselee relationship may begin by showing humane attitudes toward LGBT+ individuals in emergency rooms.

The present study revealed that participants reported exposure to maltreatment due to lack of feeling welcomed/respected within healthcare settings. Some participants specifically pointed out that unnecessary information was asked of them during interviews with physicians. This can contribute to a lack of trust between the patient and the physician. Furthermore, participants perceived these behaviours as disrespectful. Participants expect physicians to respond appropriately to treatment requests. Platforms could be founded within which healthcare professionals and LGBT+ individuals could come together and establish empathy with each other’s perceptions of healthcare provision in order to explore better methods of communication between them.

This study also revealed that participants were adversely influenced by marginalizing perceptions. Several participants reported seeking treatment because they previously perceived homosexuality as a disease. Research has consistently emphasized that homosexuality is not a disease and does not require treatment (Toscano and Maynard 2014; Kaptan and Yüksel 2014; Wahlert 2013; Drescher 2009). Nevertheless, one potential reason many LGBT+ individuals were referred to healthcare institutions is the social perception that LGBT+ identities are sinful and dysfunctional. Additionally, LGBT+ individuals and their families might prefer to see different physicians, which would hinder continuity during follow-up and treatment, potentially leading to a waste of limited sources (e.g., time and labour). Furthermore, transformation within the Turkish healthcare system over the last fifteen years has increased service consumption, resulting in citizens seeking consultancy from an average of five physicians for each health problem (TR Ministry of Health 2015). It should be noted that this phenomenon is not specific to LGBT+ individuals in Turkey.

It may be possible to ensure that LGBT+ individuals’ medical needs are appropriately met when we understand their perceptions of healthcare services. Based on the results of the current research, medical institutions and healthcare professionals may reconsider whether they provide healthcare services favouring heterosexuality. Some participants in our study presented a need to constantly explain themselves to their physicians and stated that they were disturbed by automatically being perceived as heterosexual. Efforts to understand and explain LGBT+ individuals’ ideological language should be a basic element of improving healthcare provisions. Overall, the following considerations should be made when communicating with LGBT+ individuals in healthcare settings: each person’s life experiences differ both socially and economically and their moral perspectives are not homogeneous. One of the ethical responsibilities of a medical institution is to become aware of these varied moral perspectives when engaging with LGBT+ individuals.

Conclusions and Suggestions

Results from the present study revealed that LGBT+ individuals in Turkey perceive that they are exposed to stigmatizing and marginalizing discourses when dealing with healthcare professionals, particularly when interacting with physicians. This phenomenon poses an obstacle for their health seeking behaviour. Additionally, our findings suggest that LGBT+ individuals’ capacity to utilize healthcare services is considerably influenced by their physicians’ professional approach. The prevalence of these inferences can be uncovered with large-scale quantitative research studies.

Discourses that restrict LGBT+ individuals’ living spaces within patriarchal societies such as Turkey are prevalent. Thus, collaborative measures with the Ministry of Health, professional bodies, and nongovernmental organizations working on gender identity and sexual orientation issues should be supported in order to recognize and remove marginalizing behaviours and maltreatments in healthcare settings. Organizing educational campaigns so as to increase societal awareness, particularly among healthcare professionals, regarding gender identity and sexual orientation can be instituted immediately. Research should be completed in order to better understand healthcare professionals’ perceptions of their relationship with LGBT+ individuals as patients. Moreover, medical schools and other institutional curricula should include information in their teaching regarding the healthcare needs of sexual minority individuals. Lastly, struggles to remove existing limitations for individuals first beginning to realize their LGBT+ identities and persistently advocating for healthcare equality, both in Turkey and globally, should be supported.

Footnotes

The protocol number assigned to participants was coded as followed: “Abbreviation of sexual orientation/gender identity, year of the interview, sequence number of the interviewee.” Abbreviations for sexual orientation and gender identity were arranged as follows: L: Lesbian, G: Gay, BW: Bisexual woman, BM: Bisexual man, MtF: Male to Female, FtM: Female to Male.

Daniel, H., and R. Butkus. 2015. Lesbian, gay, bisexual, and transgender health disparities: Executive summary of a policy position paper from the American College of Physicians. Health and Public Policy Committee of the American College of Physicians. Annals of Internal Medicine 163(2): 135–137.CrossRefGoogle Scholar

Drescher, J. 2009. Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior 39(2): 427–460.CrossRefGoogle Scholar

Lee, J.G., J.R. Blosnich, and C.L. Melvin. 2012. Up in smoke: Vanishing evidence of tobacco disparities in the Institute of Medicine’s report on sexual and gender minority health. American Journal of Public Health 102(11): 2041–2043.CrossRefGoogle Scholar

Mitchell, R.J., and R.J. Ozminkowski. 2017. Comparison of health risks and changes in risks over time among a sample of lesbian, gay, bisexual, and heterosexual employees at a large firm. Population Health Management 20(2): 114–122.CrossRefGoogle Scholar

Murphy, T.F. 2015. LGBT people and the work ahead in bioethics. Bioethics 29(6): ii–v.Google Scholar